NAMSCON 2018 CME ON THE RISE OF NON-COMMUNICALBLE DISEASES
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1 NAMSCON 2018 CME ON THE RISE OF NON-COMMUNICALBLE DISEASES
2 CHILDHOOD OBESITY IN INDIA CURRENT SCENARIO AND FUTURE DIRECTIONS Dr. Gunasekaran Dhandapany Professor in Pediatrics, MGMCRI.
3 Obesity an epidemic-1988
4
5 Definition of Obesity BMI Overweight: 85 th 95 th percentile Obesity: >95 th percentile IOTF: Correspond to adult equivalent BMI 25, 30 IAP: BMI 23, 27 BMI is a measure of fatness (Fat X Fat free mass) Spuriously high in muscular children; less in tall child.
6 Definition of Obesity Waist circumference WHR ratio More accurate indicators: Intra abdominal adipose tissue accumulation increased risk for cardio-metabolic risk Mid-point between inferior margin of the last rib and the iliac crest Greatest posterior protuberance of the buttocks Recent studies in adults Age-specific ref. values are not available for all the age groups
7 Prevalence of child overweight & Obesity IOTF 200 million now 268 million by 2025 USA: 7% in 1980 Every 3 rd child is overweight or obese
8 Prevalence of child overweight & Obesity India (meta-analysis of 42 studies): 16% in % in 2010 Urban >rural High SES > Low SES Boys > Girls
9 Causes for Obesity
10 Causes for Obesity Genetic Endocrine Environmental
11 Causes for Obesity Genetic Bardet-Biedel Syndrome 9 loci - Mendelian obesity 58 loci - Polygenic obesity
12 Endocrine causes for Obesity Hypothyroidism Typical facies Short stature Constipation Fatigue Dry skin Depression Irregular and/or heavy menstrual periods
13 Endocrine causes for Obesity Cushing syndrome Moon facies Buffalo hump (prominent supraclavicular and dorsal cervical fat pads) Striae Slender distal extremities and fingers
14 Endocrine causes for Obesity Polycystic Ovarian syndrome High androgen levels Acne Irregular periods Abdominal fat excess
15 Endocrine causes for Obesity Hypothalamic obesity Fast weight gain (10-20 kg in one year) Hypothalamic dysfunction (palpitation, hypertension, hyperhidrosis) Signs of ICT
16 Causes for Obesity Environmental Energy dense foods Forced feeding False traditional beliefs Energy expenditure is less: Strict academic routine Less availability of space Less number of peer group
17 Causes for Obesity Non-nutritional cause, in an adolescent: Assessment of growth velocity < 25 th percentile Bone age delay by > 2 years Cycles of menses are irregular even after 1 year of menarche Dwarfism (Short stature) Extra digits Focal Neurological deficit Genitalia hypoplastic Hypertension (>99 th percentile) Impairment of vision
18 Comorbidities of Obesity
19 Co-morbidities of overweight & Obesity Childhood obesity leads to adult obesity: 69% Risk is even more if + in adolescence.
20 Co-morbidities of overweight & Obesity Sleep: REM sleep is less Obstructive sleep apnea Behavioral problems: Poor self-esteem Depression Externalizing symptoms.
21 Co-morbidities of overweight & Obesity Hypertension: Cohort study in USA: >85 th percentile, risk is Quadrupled. Chennai: 5 times risk France: Proposed theory: Leptin, derived from adipose tissue influences sympathetic
22 Co-morbidities of overweight & Obesity Type-2 Diabetes: Fasting insulin levels more Insulin resistance is more (HOMA-IR) Potential to develop T2DM
23 Co-morbidities of overweight & Obesity Metabolic syndrome: Hypertension Insulin resistance Dyslipidemia Israel (1 million children) Australia Bogulusa heart study German study : BMI>97 th percentile: 40% are at risk
24 Co-morbidities of overweight & Obesity Endothelial dysfunction & risk of early atherosclerosis: South Indian Study: Chemical markers: MDA, FRAP, NO High levels of fibrinogen Triglycerides, VLDL
25 Co-morbidities of overweight & Obesity Others: NAFLD GERD Slipped capital femoral epiphysis
26 Co-morbidities of overweight & Obesity Premature mortality: 32 years follow-up If BMI >25 at 18 years More likely to die in the 20 years
27 Co-morbidities of overweight & Obesity 12 million: Impaired GT million: Type 2 DM 27 million: High BP 38 million: NAFLD
28 What India has to do now?
29 What India has to do now? Assess the true burden: Community & School based surveillance Health facility: screen Growth monitoring
30 What India has to do now? Role of health facilities Formulate uniform guidelines: Diagnosis & management Encourage Research Health workers-training Qualified counselors
31 What India has to do now? Interventions at school Physical activity Unhealthy foods at Cafeteria Nutrition curriculum Counseling as a group
32 What India has to do now? Interventions at home Role model Healthy eating Physical activity Restricted TV viewing Restricting junk foods
33 What India has to do now? Government s role Parks, play grounds Bicycle tracks Fruits & vegetables
34 What India has to do now? Government s role Junk food Injurious to health
35 Conclusion
36 Conclusion Childhood Obesity - epidemic proportions True burden of the problem Sensitize the public Train the health personnel Multi-disciplinary life style intervention
37 Thank you
38 Age in years Treatment of Obesity - Target Minimum aim 2-11 years Try to maintain weight If possible aim for Weight reduction of 0.5 kg / month same 1kg/week <2: no target is defined so far No compromise should be on growth
39 Aetiopathogenesis-Diet plan DISC Dietary Intervention Study for children Carbohydrate Fat Protein Fiber Others 60% 30% MUFA: 11% PUFA: 9% SFA: <8% Cholesterol not more than 150 mg/day 15% (Age in years +5) g/day Less salt Less sugar The above regimen actually applies for >8 yrs But, it is more or less same for even < 8 years The above regimen is achieved with: 6 servings of whole grain; 5 servings of fruits and vegetables; 3 servings of low fat milk /dairy products (per day)
40 Treatment- Pharmacological Name Mechanism of action Side effects In whom it is not preferable Sibutramine Serotonin noradrenaline reuptake inhibitor- thereby increasing satiety Increase in heart rate & BP Children who already have HT Orlistat (only drug, FDA approved for use in <16yr) Pancreatic lipase inhibitor; increases fecal fat loss Malabsorption (ADEK loss) diarrhoea, gall bladder disease Children who already take low fat diet Metformin Helpful to combat glucose tolerance also; hence preferred for children with impaired GT & PCOS Pharmacotherapy is only second line management; considered only when insulin resistance, impaired GT, heaptic steatosis, dyslipidemia, or severe mental dysfunction persist despite life style modifications
41 Treatment- Pharmacological- Ref: Nelson: 2016 Other approved drugs for adults: Phenteramine (noradrenergic) + Topiramate (GABAergic) Leptin + Amylin (decreases food intake + slow gastric emptying) Lorcaserin (Serotonic receptor agoinist)
42 Indications: Treatment- Bariatric Surgery BMI>40, complete or near complete skeletal maturity (>13 years in girls & >15 years in boys), presence of a medical complication resulting from obesity + 6 months of multidisciliplinary weight management program has failed Procedure of choice: Roux-en Y gastric by pass / adjustable gastric banding Complications: small bowel obstruction, incisional hernias, weight gain, vitamin def, micronutrient def, Need life long follow-up.
43 Prevention Intervention should start from NB period: Individual: Less calories, less fat; less sugar; less portion More fruits, more vegetables, Eat breakfast regularly Limit screen time < 2 hours More physical activity (brisk walking for 1 hour) Community: school, parks, walk and cycle paths Physician: Role models, regular enquiries, monitor during routine visits
44 Acceptable lipid profile Total cholesterol in mgs% LDL in mgs% Triglycerides in mgs% HDL in mgs% Comment <170 <110 <150 >35 Normal Borderline >200 >130 elevated
45 Diet management a) High fiber: age in years+ 5 = grams of fiber /day b) Good amount of fruits and vegetables: plant stanols and sterols lower the dietary absorption of cholesterol. c) Intake of trans fatty acids to be limited to <1% of total calories. d) For high risk group: saturated fat <7% & cholesterol intake <200 mgs%
46
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